Cost-Effectiveness Analysis of the Clear Cell Likelihood Score Against Renal Mass Biopsy for Evaluating Small Renal Masses.

OBJECTIVE: To examine the cost-effectiveness of the clear cell likelihood score compared to renal mass biopsy (RMB) alone. METHODS: The clear cell likelihood score, a new grading system based on multiparametric magnetic resonance imaging, has been proposed as a possible alternative to percutaneous RMB for identifying clear cell renal carcinoma in small renal masses and expediting treatment of high-risk patients. A decision analysis model was developed to compare a RMB strategy where all patients undergo biopsy and a clear cell likelihood score strategy where only patients that received an indeterminant score of 3 undergo biopsy. Effectiveness was assigned 1 for correct diagnoses and 0 for incorrect or indeterminant diagnoses. Costs were obtained from institutional fees and Medicare reimbursement rates. Probabilities were derived from literature estimates from radiologists trained in the clear cell likelihood score. RESULTS: In the base case model, the clear cell likelihood score was both more effective (0.77 vs 0.70) and less expensive than RMB ($1629 vs $1966). Sensitivity analysis found that the nondiagnostic rate of RMB and the sensitivity of the clear cell likelihood score had the greatest impact on the model. In threshold analyses, the clear cell likelihood score was the preferred strategy when its sensitivity was greater than 62.7% and when an MRI cost less than $5332. CONCLUSION: The clear cell likelihood score is a more cost-effective option than RMB alone for evaluating small renal masses for clear cell renal carcinoma.

Comparison of microwave ablation and partial nephrectomy for T1a small renal masses.

OBJECTIVE: To compare the oncological and renal function outcomes of microwave ablation (MWA) compared to partial nephrectomy (PN) in two small renal mass (SRM) tumor size cohorts, <3 cm and 3-4 cm. MATERIALS AND METHODS: This study included retrospective data from 2009 to 2015 and prospective data since 2015 from a single-institution database. Patient demographics, renal mass characteristics, and treatment outcomes were collected. Survival curves and hazard analysis were used to assess oncological outcomes. Changes in eGFR and CKD stage following surgery were used to assess renal function outcomes. RESULTS: A total of 80 PN and 126 MWA patients were analyzed. Median age and Charlson Comorbidity Index (CCI) of MWA patients were greater than PN for each tumor size cohort. Cumulative progression free survival at 36-months was 91% for MWA and 90% for PN. Preoperative renal function was significantly lower in patients undergoing MWA for both tumor sizes, however there was no significant difference in the postoperative change in renal function between MWA and PN for tumors up to 4 cm. CONCLUSIONS: Oncological outcomes and renal preservation were comparable between MWA and PN cohorts for SRMs <3cm and 3-4cm despite the MWA cohort being older and having more comorbidities. Our findings suggest that MWA can be used as a safe and effective alternative to PN for T1a renal tumors up to 4 cm.

Microwave ablation of the T1a small renal mass: expanding beyond 3 cm.

PURPOSE: To compare the oncological and renal function outcomes for patients receiving microwave ablation (MWA) in tumors < 3 and 3-4 cm. METHODS: Retrospective analysis of a prospectively maintained database identified patients with < 3 or 3-4 cm renal cancers undergoing MWA. Radiographic follow-up occurred at approximately 6 months post-procedure and annually thereafter. Serum creatinine and estimated glomerular filtration rate (eGFR) were calculated before and 6-months post-MWA. Local recurrence-free survival (LRFS) was estimated using the Kaplan-Meier method. Tumor size was evaluated as a prognostic factor using Cox proportional-hazards regression. Predictors for change in eGFR and chronic kidney disease (CKD) stage were modeled using linear and ordinal logistic regression. RESULTS: A total of 126 patients fit the inclusion criteria. Overall recurrences were 2/62 (3.2%) and 6/64 (9.4%) for < 3 versus 3-4 cm. Both recurrences in the < 3 cm group were local, 4/6 in the 3-4 cm group were local and 2/6 were metastatic without local progression. For < 3 versus 3-4 cm, cumulative LRFS at 36 months was 94.6% versus 91.4%. Tumor size was not a significant prognostic factor for LRFS. Renal function did not change significantly after MWA. Patient comorbidities and RENAL nephrometry score significantly affected change in CKD. CONCLUSION: With comparable oncological outcomes, complication rates, and renal function preservation, MWA is a promising management strategy for renal masses of 3-4 cm in select patients. Our findings suggest that current AUA guidelines, which recommend thermal ablation for tumors < 3 cm, may need review to include T1a tumors for MWA, regardless of size.

International Iohexol Shortage: Alternative Contrast Agents and Imaging Procedures for the Urologist.

INTRODUCTION: In April 2022, GE Healthcare announced a COVID-19-related interruption in iohexol manufacturing, leading to an international iodinated contrast shortage. The shortage greatly impacted urological practice, highlighting the value of alternative contrast agents and imaging/procedure alternatives. These alternatives are reviewed in this work. METHODS: A review of existing literature describing the use of alternative contrast agents, alternative imaging procedures, and contrast conservation strategies in urological care was performed using the PubMed database. The review was not performed systematically. RESULTS: Older iodinated contrast agents such as ioxaglate and diatrizoate can replace iohexol for intravascular imaging in patients without renal impairment. These agents, along with gadolinium-based agents such as Gadavist, have been used intraluminally for urological procedures and diagnostic imaging. Several lesser-known imaging and procedure alternatives are described and include air contrast pyelography, contrast-enhanced ultrasound, voiding urosonography, and low tube voltage CT urography. Conservation strategies include contrast dose reductions and use of contrast management devices for contrast vial splitting. CONCLUSIONS: The COVID-19-related iohexol shortage caused significant hardship for urological care internationally, leading to delayed contrasted imaging studies and urological procedures. Alternative contrast agents, imaging/procedure alternatives, and conservation strategies are reviewed in this work with the goal of equipping the urologist to mitigate the current iodinated contrast shortage and to prepare in the event of a future shortage.

Cost-effectiveness analysis: percutaneous microwave ablation vs robotic-assisted partial nephrectomy for small renal masses.

PURPOSE: The majority of newly diagnosed renal tumors are masses < 4 cm in size with treatment options, including active surveillance, partial nephrectomy, and ablative therapies. The cost-effectiveness literature on the management of small renal masses (SRMs) does not account for recent advances in technology and improvements in technical expertise. We aim to perform a cost-effectiveness analysis for percutaneous microwave ablation (MWA) and robotic-assisted partial nephrectomy (RA-PN) for the treatment of SRMs. METHODS: We created a decision analytic Markov model depicting management of the SRM incorporating costs, health utilities, and probabilities of complications and recurrence as model inputs using TreeAge. A willingness to pay (WTP) threshold of $100,000 and a lifetime horizon were used. Probabilistic and one-way sensitivity analyses were performed. RESULTS: Percutaneous MWA was the preferred treatment modality. MWA dominated RA-PN, meaning it resulted in more quality-adjusted life years (QALYs) at a lower cost. Cost-effectiveness analysis revealed a negative Incremental Cost-Effectiveness Ratio (ICER), indicating dominance of MWA. The model revealed MWA had a mean cost of $8,507 and 12.51 QALYs. RA-PN had a mean cost of $21,521 and 12.43 QALYs. Relative preference of MWA was robust to sensitivity analysis of all other variables. Patient starting age and cost of RA-PN had the most dramatic impact on ICER. CONCLUSION: MWA is more cost-effective for the treatment of SRM when compared with RA-PN and accounting for complication and recurrence risk.

Split-bolus CT urography after microwave ablation of renal cell carcinoma improves image quality and reduces radiation exposure.

OBJECTIVE: To compare image quality and radiation dose between single-bolus 2-phase and split-bolus 1-phase CT Urography (CTU) performed immediately after microwave ablation (MWA) of clinically localized T1 (cT1) RCC. METHODS: Forty-two consecutive patients (30 M, mean age 67.5 ± 9.0) with cT1 RCC were treated with MWA from 7/2013 to 12/2013 at two academic quaternary-care institutions. Renal parenchymal enhancement, collecting system opacification and distention and size-specific dose estimate (SSDE) were quantified and image quality subjectively assessed on single-bolus 2-phase versus split-bolus 1-phase CTU. Kruskal-Wallis and Pearson's Chi-squared tests were performed to assess differences in continuous and categorical variables, respectively. Two-sample T test with equal variances was used to determine differences in quantitative and qualitative image data. RESULTS: Median tumor diameter was larger [2.9 cm (IQR 1.7-5.3) vs 3.6 cm (IQR 1.7-5.7), p = 0.01] in the split-bolus cohort. Mean abdominal girth (p = 0.20) was similar. Number of antennas used and unenhanced CTs obtained before and during MWA were similar (p = 0.11-0.32). Renal pelvis opacification (2.5 vs 3.5, p < 0.001) and distention (4 mm vs 8 mm, p < 0.001) were improved and renal enhancement (Right: 127 HU vs 177 HU, p = 0.001; Left: 124 HU vs 185 HU, p < 0.001) was higher for the split-bolus CTU. Image quality was superior for split-bolus CTU (3.2 vs 4.0, p = 0.004). Mean SSDE for the split-bolus CTU was significantly lower [163.9 mGy (SD ± 73.9) vs 36.3 mGy (SD ± 7.7), p < 0.001]. CONCLUSION: Split-bolus CTU immediately after MWA of cT1 RCC offers higher image quality, improved opacification/distention of the collecting system and renal parenchymal enhancement at a lower radiation dose.

Analysis of executional and procedural errors in dry-lab robotic surgery experiments.

BACKGROUND: Analysing kinematic and video data can help identify potentially erroneous motions that lead to sub-optimal surgeon performance and safety-critical events in robot-assisted surgery. METHODS: We develop a rubric for identifying task and gesture-specific executional and procedural errors and evaluate dry-lab demonstrations of suturing and needle passing tasks from the JIGSAWS dataset. We characterise erroneous parts of demonstrations by labelling video data, and use distribution similarity analysis and trajectory averaging on kinematic data to identify parameters that distinguish erroneous gestures. RESULTS: Executional error frequency varies by task and gesture, and correlates with skill level. Some predominant error modes in each gesture are distinguishable by analysing error-specific kinematic parameters. Procedural errors could lead to lower performance scores and increased demonstration times but also depend on surgical style. CONCLUSIONS: This study provides insights into context-dependent errors that can be used to design automated error detection mechanisms and improve training and skill assessment.

Perioperative Cost Comparison between Percutaneous Microwave Ablation and Partial Nephrectomy for Localized Renal Masses.

INTRODUCTION: We sought to determine and compare the perioperative cost associated with percutaneous microwave ablation (MWA) and robot-assisted partial nephrectomy (RA-PN) for treatment of localized renal masses (LRMs). METHODS: We conducted a retrospective cohort analysis of a prospectively maintained IRB-approved LRM database. The database was queried for patients treated with microwave ablation or partial nephrectomy from 2015 to 2020. Allocated costs related to the procedural encounter and related to complications were collected. Allocated cost was calculated using ratio of cost-to-charges cost accounting methodology. Total cost was the sum of medical center cost and physician related cost. Statistical analysis was performed in SAS using Student's t-test and the Wilcoxon rank-sum test. RESULTS: A total of 279 patients were identified, of whom 165 underwent percutaneous MWA and 114 underwent RA-PN. All partial nephrectomies were robot-assisted. The mean total cost was $20,536 for RA-PN and $6,470 for percutaneous MWA (p <0.0001). Five patients (3%) who underwent MWA and 7 (6%) who underwent RA-PN experienced complications. Patients who underwent MWA and did not have a major complication had an average medical center cost of $5,174, compared to $8,990 for those with a major complication (p=0.36). Among patients who underwent RA-PN, those who did not have a major complication had an average medical center cost of $15,138, compared to $28,940 for those who did have a major complication (p=0.008). CONCLUSIONS: MWA demonstrates lower perioperative cost and lower cost of complications than RA-PN for treatment of LRM. Further cost-effectiveness studies for LRM treatment should be performed with this updated cost information.

Optimizing Telemedicine Technologic Infrastructure with Animal Models: A Case in Telecystoscopy.

Background: Rapid evolution of telemedicine technology requires procedures in telemedicine to adapt frequently. An example in urology, telecystoscopy, allows certified advanced practice providers to perform cystoscopy, endoscopic examination of the bladder, in rural areas with real-time interpretation and guidance by an off-site urologist. We have previously shown the technological infrastructure for optimized video quality. Introduction: Newer models of cystoscope and coder/decoder (codec) are available with anticipation that components used in our original model will become unavailable. Our objective is to assess the diagnostic ability of two cystoscopes (Storz, Wolf) with old (SX20) and new (DX70) codecs. Materials and Methods: A single urologist performed flexible cystoscopy on an ex vivo porcine bladder. Combinations of cystoscope (Storz vs. Wolf), codec (SX20 vs. DX70), and internet transmission speed were used to create eight distinct recordings. Deidentified videos were reviewed by expert urologist reviewers via electronic survey with questions on video quality and diagnostic ability. A logistic regression model was used to assess the ability to make a diagnosis. Results: Eight transmitted cystoscopy videos were reviewed by 16 urologists. Despite new technology, the Storz cystoscope combined with the SX20 codec (the original combination) provides the best diagnostic capacity. Discussion: Technical infrastructure must be routinely validated to assess the component impact on overall quality because newer is not always better. Should the SX20 become obsolete, ex vivo animal models are safe, inexpensive anatomic models for testing. Conclusions: As technology continues to evolve, procedures in telemedicine must critically scrutinize the impact of new technologic components to uphold quality.

Urologic Complications Requiring Intervention Following High-dose Pelvic Radiation for Cervical Cancer.

OBJECTIVE: To identify the incidence of radiation-induced urologic complication requiring procedural intervention following high-dose radiotherapy for cervical carcinoma, and to identify predictors of complication occurrence. MATERIALS AND METHODS: We performed a retrospective chart review of cervical cancer patients undergoing radiotherapy with primary focus on procedural complications (Clavien-Dindo ≥ III). Clinical data were collected including radiation dose, procedure performed, timing of complication, and need for additional procedures. Univariate and multivariate logistic regression modeling was performed to assess predictive value of demographic and clinical variables. RESULTS: A total of 126 patients with FIGO stage 1A2-4B cervical cancer were included in study analysis, with 18 patients experiencing procedural complication (14.3%). A total of 22 complications were identified, representing an average of 1.2 complications per patient with complication. The most common complications were ureteral stricture and radiation cystitis. The most common nononcologic procedures performed in the treatment of these complications were ureteral stenting, percutaneous nephrostomy tube placement, and cystoscopy. Notably, a total of 259 procedures were performed in the treatment of urologic complications, representing 14.4 procedures per patient and 24.6 procedures per patient with ureteral stricture. Logistic regression demonstrated active smoking at the time of diagnosis to be a predictor of procedural complication. CONCLUSION: Radiotherapy in the treatment of cervical cancer is associated with a high rate of urologic procedural complication. These complications often require numerous procedures and long-term management given their complexity. These findings suggest a need for awareness and plans for multidisciplinary management of urologic complications in this patient population.

Blinded Comparison of Clarity, Proficiency and Diagnostic Capability of Tele-Cystoscopy Compared to Traditional Cystoscopy: A Pilot Study.

PURPOSE: In order to expand the availability of cystoscopy to underserved areas we have proposed using advanced practice providers to perform cystoscopy with real-time interpretation by the urologist on a telemedicine platform, termed "tele-cystoscopy." The purpose of this study is to have blinded external reviewers retrospectively compare multisite, prospectively collected video data from tele-cystoscopy with the video of traditional cystoscopy in terms of video clarity, practitioner proficiency and diagnostic capability. MATERIALS AND METHODS: Each patient underwent tele-cystoscopy by a trained advanced practice provider and traditional cystoscopy with an onsite urologist. Prospectively collected tele-cystoscopy transmitted video, tele-cystoscopy onsite video and traditional cystoscopy video were de-identified and blinded to external reviewers. Each video was evaluated and rated twice by independent reviewers and diagnostic agreement was quantified. RESULTS: Six tele-cystoscopy encounters were reviewed for a total of 36 assessments. Video clarity, defined by speed of transmission and image resolution, was better for onsite compared to transmitted tele-cystoscopy. Practitioner proficiency for thoroughness of inspection was rated at 92% for tele-cystoscopy and 100% for traditional cystoscopy. Confidence in identification of an abnormality was equivalent. Four of 6 videos had 100% agreement between reviewers for next action taken, indicating high diagnostic agreement. Additionally, provider performing cystoscopy and location did not statistically influence the ability to make a diagnosis or action taken. CONCLUSIONS: This model has excellent completeness of examination, equivalent ability to identify abnormalities and external validation of action taken. This pilot study demonstrates that tele-cystoscopy may expand access to bladder cancer surveillance.

Modified Whitaker test: a novel diagnostic for nephroptosis.

A 77-year-old woman presented with right flank pain radiating to the ipsilateral groin and associated nausea, consistent with renal colic. In the emergency department, a non-contrast CT scan revealed severe right-sided hydronephrosis but failed to demonstrate a calculus or ureteropelvic obstruction. The patient improved with fluids and followed up with a community urologist. Initial work-up with cystoscopy and ureteroscopy, voiding cystourethrogram and diuretic renography failed to deduce a diagnosis. At our hospital, we used a modified dynamic (supine and upright) Whitaker test in a novel fashion to diagnose nephroptosis, a rare hypermobility condition of the kidney.

Effect of active versus passive void trials on time to patient discharge, urinary tract infection, and urinary retention: a randomized clinical trial.

PURPOSE: We sought to determine the effect of active versus passive voiding trials on time to hospital discharge and rates of urinary tract infection (UTI) and urinary retention (UR). METHODS: We performed a prospective, randomized trial comparing active (AVT) versus passive (PVT) void trials of inpatients requiring urethral catheter removal. Of 329 eligible patients, 274 were randomized to AVT (bladder filled with saline before catheter removal) or PVT (spontaneous bladder filling after catheter removal). Primary outcome was time to hospital discharge. Secondary outcomes were UTI (NSQIP criteria) and UR (requiring repeat catheterization) within 2 weeks of void trial. RESULTS: The median time to void was 18 (5-115) versus 236 (136-360) min in the AVT and PVT groups, respectively (p < 0.0001). However, no difference was seen in comparison of the median time to hospital discharge between AVT [28.4 (13.6-69.3) h] and PVT [30.0 (10.4-75.6) h] cohorts, respectively (p = 0.93). Six (4.8%) and 13 (12.9%) patients developed UTI in the AVT and PVT groups, respectively (p = 0.03). Eleven (8.8%) and 12 (11.9%) patients developed UR in the AVT and PVT groups, respectively (p = 0.36). CONCLUSION: Our study comparing AVT versus PVT demonstrated no difference in time to discharge despite a 3.6 h reduction in time to void associated with AVT. AVT was associated with a 63% reduction in UTI, with no difference seen in UR rates across cohorts. Given the reduction in UTI and technical advantages, our data suggest that AVT should be considered as a recommended technique for void trial protocol. TRIAL REGISTRATION: NCT02886143 (clinicaltrials.gov).

Thermal ablation of the small renal mass: a critical analysis of current literature.

INTRODUCTION: Thermal ablation is increasingly utilized as a management strategy for small renal masses (<4 cm). Partial nephrectomy is recognized as the gold standard; thermal ablation has been reserved for older patients with comorbidities due to concern for local tumor recurrence. As long-term data regarding the safety and efficacy of ablative techniques accumulate with encouraging results, clinicians are widening the utility in select patient populations. This review summarizes the currently available technologies in terms of procedural differences, oncologic outcomes, renal function, and complication rates. EVIDENCE ACQUISITION: A structured literature review was conducted using PubMed and Web of Science, using the keywords: "renal cell carcinoma," "ablation techniques," "cryosurgery," "radiofrequency ablation," "microwave ablation," "outcomes assessment," "post-operative complication," and "hospital costs." Articles were reviewed to summarize oncologic outcomes, complications, and impact on renal function of cryoablation, radiofrequency ablation, and microwave ablation. EVIDENCE SYNTHESIS: Thermal ablation is a safe and effective management option for small renal masses in select patients, particularly in those with multiple tumors and/or those unable or unwilling to undergo more invasive surgery. Slightly higher rates of local recurrence rates (~1-10%) with thermal ablation are offset by lower complication rates and reduced morbidity, and equivalent or better renal function outcomes compared to surgery. CONCLUSIONS: The established modalities of cryo-, radiofrequency, and microwave ablation offer equivalent outcomes with similar complication rates; technique choice is primarily based on tumor characteristics and operator preference. Better quality evidence comparing thermal ablation with surgical nephron-sparing intervention is needed to make informed conclusions on efficacy.

Tele-Urology During COVID-19: Rapid Implementation of Remote Video Visits.

INTRODUCTION: COVID-19 has brought unprecedented challenges to the delivery of urological care. Following rapid implementation of remote video visits at our tertiary academic medical center serving a large rural population we describe and assess our experience with planned video visits and ongoing scheduling efforts. METHODS: Patients scheduled for video visits between April 14 and April 27, 2020 were included. Prospective and retrospective data were collected on patient and clinical characteristics as well as telemedicine outcomes. Multivariable logistic regression was performed to evaluate factors influencing video visit success. Concurrently scheduling data were collected from a separate cohort regarding patient access to technology and willingness to participate in video visits. RESULTS: A total of 209 patients were included with an overall video visit success rate of 67%. Of video visits that failed (69) reasons included no-show (35%), inability to connect to the telemedicine platform (23%) and lack of Internet access (10%). Nearly half of failed video visits (46.4%) were completed as phone visits. After adjustment for patient demographics commercial insurance was significantly associated with video visit success. In assessment of scheduling outcomes 179 patients were contacted to offer video visits. Of these patients 6.7% reported not having Internet access. Of those with Internet access 87% agreed to proceed with a video visit in lieu of visiting in person. CONCLUSIONS: Our experience indicates that rapid implementation of video telemedicine is feasible and highly accepted by patients. Efforts focused on standardized pre-visit patient education may further optimize successful telemedicine visits.

Multi-Institutional Collaborative Resident Education in the Era of COVID-19.

INTRODUCTION: The 2019-2020 coronavirus pandemic has had a significant impact on all aspects of health care. Decrease in clinical and operative volume and limitations for conferences has drastically decreased educational opportunities for resident trainees. We describe the formation and initial success of the Collaborative Online Video Didactics lecture series, a multi-institutional online video didactics collaboration. METHODS: Zoom data extraction and postlecture evaluation surveys were used to collect data on the impact of the pandemic on local educational activities as well as feedback about the lecture series. Lectures are being given by faculty from 35 institutions. The twice daily, hour-long webinar averages more than 470 live viewers per session with an average of 33.5 questions per session and has over 7,000 YouTube views of the recordings after the first 2 weeks. RESULTS: Viewers reported significant decreases in outpatient (75.2%), inpatient (64.9%) and operating room (77.7%) volumes at local programs, and only half (52.7%) of the survey responders indicated an increase in didactics locally. The lectures have been well-received, with over 90% of respondents giving the lecturers and series above average or excellent ratings. A significant majority of responders indicated that the lecture series has allowed for ongoing education opportunities during the pandemic (95.0%), helped to access faculty experts from other institutions (92.3%) and provided a sense of community connectedness during this period of social isolation (81.7%). CONCLUSIONS: We strongly encourage other institutions and trainees to participate in the didactic series and hope that this series can continue to evolve and be of benefit beyond the pandemic.

Does renal mass biopsy influence multidisciplinary treatment recommendations?

Purpose: To examine how a multidisciplinary team approach incorporating renal mass biopsy (RMB) into decision making changes the management strategy.Methods: A multidisciplinary team comprised of a radiology proceduralist, a pathologist and urologists convened monthly for renal mass conference with a structured presentation of patient demographics, co-mborbidities, tumor pathology, laboratory and radiographic features. Biopsy protocol was standardized to an 18-gauge core needle biopsy using a sheathed apparatus under renal ultrasound guidance. Biopsy diagnostic rate, and concordance with nephrectomy specimens were summarized. Descriptive statistics were used to evaluate influence of RMB on management decisions.Results: A total of 83 patients with a ≤4 cm mass were discussed, and 66% of patients underwent RMB. Of those, 87% were diagnostic with 9% of core biopsies showing benign pathology. Active surveillance (AS) was recommended for 34% of patients with biopsy data as compared to 64% of those without biopsy. Ablation was recommended for 38% of the biopsy cohort compared to 7% without biopsy. Partial nephrectomy rates were similar for both cohorts, approximately 17% and 22%, respectively. Our complication rate was 1.5%, with only 1 Clavien-Dindo Grade 2 complication. Histology was concordant in 93% of patients that ultimately underwent partial nephrectomy after biopsy.Conclusions: Over half of our SRM patients underwent a RMB that provided a diagnosis in 85% of cases. RMB aided in shared decision making by providing insight into the biology of renal masses, which helps to guide multidisciplinary management and consideration of nephron sparing options.

Creation of a Novel Digital Rectal Examination Evaluation Instrument to Teach and Assess Prostate Examination Proficiency.

OBJECTIVE: To create a validated tool to measure digital rectal examination proficiency and aid with teaching of the examination. DESIGN: The Digital Rectal Examination Clinical Tool was created using a modified Delphi method with 5 urologists and 5 radiation oncologists. The instrument was then validated in a population of preclinical medical students examining male urological teaching associates, and clinical trainees (third- and fourth-year medical students and urology resident physicians) examining prospectively enrolled subjects. Trainees completed paired examinations with an attending urologist, and responses were scored with reference to the attending responses. SETTING: The instrument was validated at the University of Virginia in the urology clinic, endoscopic operating room, and main operating room settings. PARTICIPANTS: We tested the instrument on consenting subjects consisting of male urologic teaching associates (n = 12), clinic patients (n = 4), and operating room patients (n = 64). The participants were undergraduate (n = 302) and graduate (n = 9) medical trainees. RESULTS: In preclerkship trainees, improved scores in subjects without abnormal compared to those with abnormal findings demonstrated validity. In clinical trainees, scores on the Digital Rectal Examination Clinical Tool increased by 2% for each additional year of training, demonstrating construct validity. CONCLUSIONS: We used an expert panel to create a novel instrument for measuring digital rectal examination proficiency and validated it with preclinical and clinical trainee cohorts at our institution.

Does Robotic Surgical Simulator Performance Correlate With Surgical Skill?

OBJECTIVE: To assess the relationship between robotic surgical simulation performance and the real-life surgical skill of attending surgeons. We hypothesized that simulation performance would not correlate with real-life robotic surgical skill in attending surgeons. DESIGN: In 2013, Birkmeyer et al. demonstrated an association between laparoscopic surgical performance as determined by expert review of video clips and surgical outcomes. Using that model of expert review, we studied the relationship between robotic simulator performance and real-life surgical skill. Ten attending robotic surgeons performed 4 tasks on the da Vinci Skills Simulator (Camera Targeting 1, Ring Walk 3, Suture Sponge 3, and Energy Dissection 3). Two video clips of a robotic-assisted operation were then recorded for each surgeon. Three expert robotic surgeons reviewed the recordings and rated surgical technique using the Global Evaluative Assessment of Robotic Skills. SETTING: University of Virginia; Charlottesville, VA; tertiary hospital PARTICIPANTS: All attending surgeons who perform robotic-assisted surgery at our institution were enrolled and completed the study. RESULTS: The surgeons had a median of 7.25 years of robotic surgical experience with a median of 91 cases (ranging: 20-346 cases) in the last 4 years. Median scores for each simulator task were 87.5%, 39.0%, 77.5%, and 81.5%. Using Pearson's correlation, scores for each of the individual tasks correlated poorly with expert review of intraoperative performance. There was also no correlation (r = -0.0304) between overall simulation score (mean: 70.7 ± 9.6%) and expert video ratings (mean: 3.66 ± 0.32 points). CONCLUSIONS: There was no correlation between attending surgeons' simulator performance and expert ratings of intraoperative videos based on the Global Evaluative Assessment of Robotic Skills scale. Although novice surgeons may put considerable effort into training on robotic simulators, performance on a simulator may not correlate with attending robotic surgical performance. Development of simulation exercises that guide novice surgeons toward expert performance is needed.

Remote Development of Tumor-to-Tumor Metastasis of Breast Adenocarcinoma in a Renal Oncocytoma.

Tumor-to-tumor metastasis (TTM) is a rare phenomenon where a focus of distinct metastatic disease is discovered with a second primary tumor. Although renal cell carcinoma is the most frequent recipient of metastatic tumor cells, oncocytomas have also previously been described. We present the case of a patient with incidentally detected mammary adenocarcinoma within an oncocytoma 16 years following primary treatment. The mass was treated with partial nephrectomy, with the surgical pathology specimen showing clear delineation of the pleomorphic lobular carcinoma and oncocytoma cells.